Missed Questions

knee gatch

Elevating this can put pressure on the popliteal space, restrict circulation and increase the risk of thrombophlebitis.

Cholecystokinin

a hormone that is secreted by cells in the duodenum and stimulates the release of bile into the intestine and the secretion of enzymes by the pancreas.

Raynaud's disease

a peripheral arterial occlusive disease in which intermittent attacks are triggered by cold or stress

decompensated shock

when the body can no longer compensate for low blood volume or lack of perfusion. Late signs such as decreasing blood pressure become evident

multigravida

woman who has been pregnant more than once

SBAR communication

(Situation, Background, Assessment, Recommendation) - framework for communication between members of the healthcare team about a patient's condition.

incomplete abortion

Expulsion of the fetus with retained placenta before 20 weeks' gestation.

Which term should the nurse use to describe a flat, poorly defined mass on the sole over a bony prominence caused by pressure? 1 Plantar wart 2 Callus 3 Ingrown nail 4 Hypertrophic ungual labium

2 In foot problems, callus is described as a flat, poorly defined mass on the sole over a bony prominence that is caused by pressure. Plantar wart is a painful papillomatous growth caused by a virus. A sliver of toenail penetrating the skin and causing inflammation results in ingrown nail. Hypertrophic ungual labium is described as chronic hypertrophy of the nail lip caused by improper nail trimming.

The nurse assists a client to the bathroom to void several times during the first stage of labor. Why is this is an important component of nursing? 1 A full bladder is often injured during labor. 2 A full bladder may inhibit the progress of labor. 3 A full bladder jeopardizes the status of the fetus. 4 A full bladder predisposes the client to urinary infection

2 A full bladder encroaches on the uterine space and impedes the descent of the fetal head. The bladder may become atonic, but is not physically damaged during the course of labor. A full bladder may lead to prolonged labor, but generally does not jeopardize fetal status as long as adequate placental perfusion continues. A full bladder during labor does not predispose the client to infection.

A 22-year-old primigravida is admitted to the hospital in labor. After performing a vaginal examination, the nurse determines that the client's cervix is dilated 2 cm and 80% effaced and that the presenting part is at 0 station. What is the location of the presenting part? 1 Entering the vagina 2 Floating within the bony pelvis 3 At the level of the ischial spines 4 Above the level of the ischial spines

3 The ischial spines are used as landmarks in relation to the fetus's head, because they reflect the progression of labor; 0 station indicates that the presenting part is at the ischial spines. When the head enters the vagina it is below the ischial spines and its position is designated with positive numbers (+1 to +4). When the presenting part is floating, the fetus is at -5 station. A position above the ischial spines is designated by a minus number (-1 to -4).

What is the function of limbic system? 1 Influence emotional behavior 2 Regulate autonomic functions 3 Facilitate automatic movements 4 Relay sensory and motor inputs for cerebrum

1 Located lateral to the hypothalamus, the limbic system influences emotional behavior and basic drives such as feeding and sexual behaviors. The regulation of endocrine and autonomic functions is the function of the hypothalamus. The control and facilitation of learned and automatic movements is the function of the basal ganglia. The thalamus relays sensory and motor input to and from the cerebrum.

carotid sinus massage

the physician massages over one carotid artery for a few seconds, observing for a change in cardiac rhythm.

Tertiary preventive care

-Goal is to stop disease progression; return to pre-illness state -Medications, Surgical Treatment, Physical Therapy/Rehabilitation

preclampsia

abnormal condition encountered during pregnancy or shortly after delivery characterized by high blood pressure, edema, and proteinuria, but with no convulsions or coma

A client, experiencing an exacerbation of Crohn disease, is admitted to the hospital for intravenous steroid therapy. The nurse should not assign this client to a room with a roommate who has which illness? 1 Pancreatitis 2 Thrombophlebitis 3 Bacterial meningitis 4 Acute cholecystitis

3

Factor V Leiden

Most common hypercoagulable state, mutated factor V that is resistant to , Protein C and Protein S cleavage.

multiparous

a woman who has given birth two or more times

A child has been diagnosed with hemophilia type A after experiencing excessive bleeding from a minor trauma. How is hemophilia inherited? 1 X-linked recessive trait 2 Y-linked recessive trait 3 X-linked dominant trait 4 Y-linked dominant trait

1 Hemophilia A is an X-linked recessive trait, not a dominant trait, meaning daughters who have the gene are carriers, and sons with the gene have the condition. The trait is not carried on the Y chromosome.

What information does the nurse need to teach a client in order for her to perform an accurate breast self-examination? 1 Squeeze the nipples to examine for discharge. 2 Use the right hand to examine the right breast. 3 Place a pillow under the shoulder opposite the examined breast to raise it. 4 Compress breast tissue to the chest wall with the palm to palpate for lumps.

1 Serous or bloody discharge from the nipple is pathologic and must be reported. The right hand should be used to examine the left breast because this allows the flattened fingers to palpate the entire breast, including the tail (upper, outer quadrant toward the axilla) and axillary area. A small pillow or rolled towel should be placed under the scapula of the side being examined because it helps raise the chest wall and spread and flatten out breast tissue. The flat part of the fingers, not the palm or fingertips, should be used for palpation.

Which gerontologic assessment findings of the auditory system are related to the inner ear? Select all that apply. 1 Hair cell degeneration 2 Reduced blood supply to the cochlea 3 Atrophic changes of the tympanic membrane 4 Decline in the ability to filter out unwanted sounds 5 Less effective vestibular apparatus in the semicircular canals

1,2,5 Hair cell degeneration, reduced blood supply to the cochlea, and less effective vestibular apparatus in the semicircular canals are assessment findings related to the inner ear. Atrophic changes of the tympanic membrane is an assessment finding associated with the middle ear. A decline in an ability to filter out unwanted sounds is an assessment finding related to the brain.

Which hormone elevations indicate Turner syndrome? Select all that apply. 1 Lutropin 2 Prolactin 3 Follitropin 4 Testosterone 5 Progesterone

1, 3 Elevation of lutropin and follitropin indicates Turner syndrome. Elevation of prolactin indicates possible galactorrhea, pituitary tumor, disease of hypothalamus or pituitary gland, and hypothyroidism. Elevated testosterone levels in women indicate adrenal neoplasm, ovarian neoplasm, and polycystic ovary syndrome. Elevated progesterone levels in men indicate possible testicular tumors and hyperthyroidism. Elevated progesterone levels in women indicate possible ovarian luteal cysts.

On the morning of surgery a client is admitted for resection of an abdominal aortic aneurysm. While awaiting surgery, the client suddenly develops symptoms of shock. Which nursing action is priority? 1 Prepare for blood transfusions. 2 Notify the surgeon immediately. 3 Make the client nothing by mouth (NPO). 4 Administer the prescribed preoperative sedative.

2 Immediate surgical intervention to clamp the aorta is necessary for survival; the aneurysm has ruptured. Preparing for blood transfusions may be done eventually, but notifying the surgeon is the priority. The client is already NPO. Sedatives mask important signs and symptoms of shock.

Thick mucous gland secretions, elevated sweat electrolytes, meconium ileus, and difficulty maintaining and gaining weight are associated with which autosomal recessive disorder? 1 Cerebral palsy 2 Cystic fibrosis 3 Muscular dystrophy 4 Multiple sclerosis

2 The early symptom of cystic fibrosis is meconium ileus, which is impacted stool in the newborn. Thick mucous secretions, salty sweat, and difficulty gaining weight because of high caloric demands are characteristics of the condition. Cerebral palsy is a motor disorder caused by damage to the brain. Muscular dystrophy is a muscular disorder. Multiple sclerosis is a condition with progressive disintegration of the myelin sheath.

A client is admitted to the hospital with a diagnosis of Crohn disease. What is most important for the nurse to include in the teaching plan for this client? 1 Controlling constipation 2 Meeting nutritional needs 3 Preventing increased weakness 4 Anticipating a sexual alteration

2 To avoid gastrointestinal pain and diarrhea, these clients often refuse to eat and become malnourished. The consumption of a high-calorie, high-protein diet is advised. Diarrhea, not constipation, is a problem with Crohn disease. Preventing an increase in weakness is a secondary concern that results from malnutrition; correcting the malnutrition will increase strength. Anticipating a sexual alteration generally is not a problem with Crohn disease.

When an intestinal obstruction is suspected, a client has a nasogastric tube inserted and attached to suction. What response should the nurse critically assess on this client? 1 Edema 2 Belching 3 Fluid deficit 4 Excessive salivation

3 Dehydration is a danger because of fluid loss with gastrointestinal (GI) suction. Based on the data provided, edema, belching, and excessive salivation are not likely to occur.

While obtaining the client's health history, which factor does the nurse identify that predisposes the client to type 2 diabetes? 1 Having diabetes insipidus 2 Eating low-cholesterol foods 3 Being 20 pounds (9 kilograms) overweight 4 Drinking a daily alcoholic beverage

3 Excessive body weight is a known predisposing factor to type 2 diabetes; the exact relationship is unknown. Diabetes insipidus is caused by too little antidiuretic hormone (ADH) and has no relationship to type 2 diabetes. High-cholesterol diets and atherosclerotic heart disease are associated with type 2 diabetes. Alcohol intake is not known to predispose a person to type 2 diabetes.

A nurse is advising a client about the risks associated with failing to seek treatment for acute pharyngitis caused by beta-hemolytic streptococcus. For what health problem is the client at risk? 1 Asthma 2 Anemia 3 Endocarditis 4 Reye syndrome

3 Streptococcal infection can be spread through the circulation to the heart; endocarditis results and affects the valves of the heart. Asthma, anemia, and Reye syndrome are not caused by beta-hemolytic streptococcus.

What are the cardiovascular manifestations observed in a client with adrenal insufficiency? 1 Fatigue 2 Salt craving 3 Weight loss 4 Hyponatremia

4 Hyponatremia is a decrease in serum sodium levels, which is the cardiovascular manifestation of adrenal insufficiency. Fatigue is a neuromuscular manifestation observed in clients with adrenal insufficiency, while salt cravings and weight loss are the abdominal manifestations observed in clients with adrenal insufficiency.

amniocentesis

A technique of prenatal diagnosis in which amniotic fluid, obtained by aspiration from a needle inserted into the uterus, is analyzed to detect certain genetic and congenital defects in the fetus.

episiotomy

surgical incision of the perineum to enlarge the vagina and so facilitate delivery during childbirth

Misoprostol

PGE1 derivative: orally active prostaglandin used to prevent peptic ulcers in patients taking NSAIDs for arthritis. Tox: diarrhea

gerontological

Pertaining to the study of the non-medical problems of the aged

Addison Disease S/S

Steroid Abuse/Chronic use Hypovolemia/glycemia/natremia Loss of Body Hair Hyperpigmentation

ascites

abnormal accumulation of fluid in the abdomen

gastric lavage

cleansing procedure in which the stomach is irrigated with a prescribed solution

Titrate

continuously measure and adjust the balance of (a physiological function or drug dosage).

Somogyi effect

hypoglycemia followed by rebound hyperglycemia

Addison's disease

occurs when the adrenal glands do not produce enough of the hormones cortisol or aldosterone

dysmenorrhea

painful menstruation

amenorrhea

absence of menstruation

cardiac tamponade

acute compression of the heart caused by fluid accumulation in the pericardial cavity

pulmonary capillary wedge pressure (PCWP)

- indicates Left ventricular failure. - Fluid overload.

A client has edema in the lower extremities during the day, which disappears at night. With which medical problem does the nurse conclude this clinical finding is consistent? 1 Pulmonary edema 2 Myocardial infarction 3 Deep vein thrombosis 4 Right ventricular heart failure

4 Right ventricular heart failure causes increased pressure in the systemic venous system, which leads to a fluid shift into the interstitial spaces. Because of gravity, the lower extremities are first affected in an ambulatory client. Pulmonary edema results in severe respiratory distress and peripheral edema with pink frothy sputum. Myocardial infarction itself does not cause peripheral edema. The edema in deep vein thrombosis will be constant and not disappear at night; redness is usually present.

Acculturation

The adoption of cultural traits, such as language, by one group under the influence of another.

Factor V Leiden mutation

The most common inherited cause of hypercoagulability.

Legg-Calvé-Perthes disease

a self-limiting disorder in which there is aseptic necrosis of the femoral head. The aims of treatment are to eliminate hip irritability; restore and maintain adequate range of hip motion; prevent capital femoral epiphyseal collapse, extrusion, or subluxation; and ensure a well-rounded femoral head at the time of healing.

Methicillin-resistant Staphylococcus aureus (MRSA)

a strain of the bacterium Staphylococcus aureus that has become resistant to the antibacterial action of the antibiotic methicillin, a form of penicillin

preeclampsia

abnormal condition associated with pregnancy, marked by high blood pressure, proteinuria, edema, and headache

Cushing syndrome

excess cortisol secretion that doesn't depend on stimulation from ACTH and is associated with disorders of the adrenal glands. The most common of these disorders is a noncancerous tumor of the adrenal cortex, called an adrenal adenoma.

climacteric

midlife transition in which fertility declines

When the cervix of a woman in labor is dilated 9 cm, she states that she has the urge to push. Which action should the nurse implement at this time? 1 Having her pant-blow during contractions 2 Placing her legs in stirrups to facilitate pushing 3 Encouraging her to bear down with each contraction 4 Reviewing the pushing techniques taught in childbirth classes

1

Which type of cranial surgery involves opening the cranium with a drill? 1 Burr hole 2 Craniotomy 3 Craniectomy 4 Cranioplasty

1 A burr hole involves the opening of the cranium using a drill. A craniotomy is a cranial surgery that involves opening the cranium with the removal of the bone flap and opening the dura to remove the lesion. A craniectomy is an excision into the cranium to cut away a bone flap. A cranioplasty is the repair of a cranial defect caused by trauma.

The nurse discusses the recommended weight gain during pregnancy with a newly pregnant client who is 5 ft 3 in (160 centimeters) tall and weighs 130 lb (57 kilograms). The nurse explains that with the recommended weight gain, at term the client should weigh how much? 1 150 lb (68 kg) 2 140 lb (63.5 kg) 3 135 lb (61 kg) 4 130 lb (57 kg)

1 A weight of 150 lb (68 kg) would put the client within the recommended weight gain of at least 25 lb (11 kg) for a woman who was of average weight for her height before pregnancy. A weight of 140 lb (63.5 kg) is less than the recommended weight gain for a woman of average weight for height before pregnancy, as are 135 lb (61 kg) and 130 lb (57 kg). Recommendations are that women with a normal body mass index (BMI) should gain 25 to 35 lb (11.3 to 15.9 kg) during pregnancy.

A pregnant client is admitted with abdominal pain and heavy vaginal bleeding. What is the priority nursing action? 1 Administering oxygen 2 Elevating the head of the bed 3 Drawing blood for a hematocrit level 4 Giving an intramuscular analgesic

1 Abdominal pain and heavy vaginal bleeding indicate significant blood loss. To compensate for decreased cardiac output, oxygen is given to maintain the well-being of both mother and fetus. Elevating the head of the bed will decrease blood flow to vital centers in the brain. Drawing blood for a hematocrit level is not the priority. Giving an intramuscular analgesic may mask abdominal pain and sedate an already compromised fetus; also, it requires a primary healthcare provider's prescription.

A nurse is caring for a client with Addison disease. Which dietary instruction should the nurse teach the client to follow? 1 Add extra salt to food 2 Consume high-potassium foods 3 Omit protein foods at each meal 4 Restrict the daily intake of fluids to 1 L

1 Because of diminished mineralocorticoid secretion, clients with Addison disease are prone to developing hyponatremia. Therefore, the addition of salt to the diet is advised. Clients with Addison disease are prone to hyperkalemia. High-potassium foods can be restricted. Protein is not omitted from the diet; ingestion of essential amino acids is necessary for optimum metabolism and healing. Fluids are not restricted for clients with Addison disease.

A client has surgery for the creation of a colostomy. Postoperatively, what color does the nurse expect a viable stoma to be? 1 Brick red 2 Pale pink 3 Light gray 4 Dark purple

1 Brick red describes a stoma that has adequate vascular perfusion. Pale pink indicates inadequate perfusion of the stoma. Light gray is indicative of poor tissue perfusion. Dark purple indicates inadequate perfusion of the stoma.

What is the priority nursing intervention during the admission of a primigravida in labor? 1 Monitoring the fetal heart rate 2 Asking the client when she ate last 3 Obtaining the client's health history 4 Determining whether the membranes have ruptured

1 Determining fetal well-being supersedes all other measures; if the fetal heart rate is absent or persistently decelerating, immediate intervention is required. The health history, including the client's last meal and whether the membranes have ruptured, may be taken once fetal well-being has been established.

A client is in the intensive care unit. The nurse observing the telemetry monitor identifies flattening T waves and peaked P waves. What problem should the nurse consider based on these ECG changes? 1 Hypokalemia 2 Hypocalcemia 3 Hyponatremia 4 Hypomagnesemia

1 Flattened or inverted T waves, peaked P waves, depressed ST segments, and elevated U waves are associated with hypokalemia. Prolongation of the QT interval may indicate hypocalcemia. Hyponatremia is not reflected in the heart's electrical conduction. Although flattening of T waves may occur with hypomagnesemia, the ST segment may be shortened, and the PR and QRS intervals may be prolonged.

A nurse is collecting data from a client with varicose veins who is to have sclerotherapy. What should the nurse expect the client to report? 1 Feeling of heaviness in both legs 2 Intermittent claudication of the legs 3 Calf pain on dorsiflexion of the foot 4 Hematomas of the lower extremities

1 Impaired venous return causes increased pressure, with symptoms of fatigue and heaviness. Pain when walking relieved by rest (intermittent claudication) is a symptom related to hypoxia. Symptoms of hypoxia are related to impaired arterial, rather than venous, circulation. Calf pain on dorsiflexion of the foot is Homans sign, which is suggestive of thrombophlebitis. Ecchymoses may occur in some individuals, but bleeding into tissue is insufficient to cause hematomas.

After a client has a total gastrectomy, the nurse plans to include in the discharge teaching the need for what treatment? 1 Monthly injections of cyanocobalamin 2 Regular daily use of a stool softener 3 Weekly injections of iron dextran 4 Daily replacement therapy of pancreatic enzymes

1 Intrinsic factor is lost with removal of the stomach, and cyanocobalamin is needed to maintain the hemoglobin level once the client is stabilized; injections are given monthly for life. Adequate diet, fluid intake, and exercise should prevent constipation. Weekly injections of iron dextran are not considered routine. Daily replacement therapy of pancreatic enzymes does not affect pancreatic enzymes.

A client's arterial blood gas report indicates that pH is 7.25, Pco2 is 60 mm Hg, and HCO3 is 26 mEq/L (26 mmol/L). Which client should the nurse consider is most likely to exhibit these blood gas results? 1 A 65-year-old with pulmonary fibrosis 2 A 24-year-old with uncontrolled type 1 diabetes 3 A 45-year-old who has been vomiting for 3 days 4 A 54-year-old who takes sodium bicarbonate for indigestion

1 The low pH and elevated Pco2 are consistent with respiratory acidosis, which can be caused by pulmonary fibrosis, which impedes the exchange of oxygen and carbon dioxide in the lung. A 24-year-old with uncontrolled type 1 diabetes most likely will experience metabolic acidosis from excess ketone bodies in the blood. A 45-year-old who has been vomiting for 3 days most likely will experience metabolic alkalosis from the loss of hydrochloric acid from vomiting. A 54-year-old who takes sodium bicarbonate for indigestion most likely will experience metabolic alkalosis from an excess of base bicarbonate.

A client is on a cardiac monitor. The monitor begins to alarm showing ventricular tachycardia. What should the nurse do first? 1 Check for a pulse 2 Start cardiac compressions 3 Prepare to defibrillate the client 4 Administer oxygen via an ambu bag

1 The treatment of ventricular tachycardia depends on the presence of a pulse. Therefore checking for a pulse is the first priority for the nurse. The nurse must rely on client assessment, not solely on the monitor. Cardiac compressions would not be initiated if there was a pulse. Administering oxygen via an ambu bag would only occur if the client was not breathing. The client is not automatically defibrillated. Cardioversion is recommended for slower ventricular tachycardia.

During discharge teaching a client who just had a hysterectomy states, "After this surgery, I don't expect to be interested in sex anymore." What should the nurse consider before responding? 1 Many women believe that their sexual function is related to their uterus. 2 Surgically forced menopause usually results in a decreased sex drive. 3 The loss of estrogen that results from this surgery will cause most women to experience a decrease in libido. 4 Body image changes that occur after this surgery prevent many women from resuming sexual activity.

1 The uterus is often erroneously believed necessary for a satisfying sex life. Sexuality after hysterectomy should not be diminished, particularly because the fear of pregnancy no longer exists. Although the estrogen level is reduced, libido is influenced by psychologic as well as hormonal factors. Although body image changes can interfere with sexuality, this is not an expectation for most women.

Which statements regarding the involution process are correct? Select all that apply. 1 Involution begins immediately after expulsion of the placenta. 2 Involution is the self-destruction of excess hypertrophied tissue. 3 Involution progresses rapidly during the next few days after birth. 4 Involution is the return of the uterus to a nonpregnant state after birth. 5 Involution may be caused by retained placental fragments and infections.

1,3,4 The involution process is the return of the uterus to a nonpregnant state after birth; it begins immediately after expulsion of the placenta and contraction of the uterine smooth muscle. This process progresses rapidly during the first few days after birth. Subinvolution is the self-destruction of excess hypertrophied tissue; this process may be caused by retained placental fragments or infection.

A client is experiencing an exacerbation of ulcerative colitis. A low-residue, high-protein diet and IV fluids with vitamins have been prescribed. When implementing these prescriptions, which goal is the nurse trying to achieve? 1 Reduce gastric acidity 2 Reduce colonic irritation 3 Reduce intestinal absorption 4 Reduce bowel infection rate

2 A low-residue diet is designed to reduce colonic irritation, motility, and spasticity. Reduction of gastric acidity is the aim of bland diets used in the treatment of gastric ulcers. Reducing colonic irritation, motility, and spasticity hopefully will increase, not reduce, intestinal absorption. This diet is to allow the bowel to rest, not to reduce infection rates.

A 42-year-old client at 39 weeks' gestation has a reactive nonstress test (NST). What should the nurse explain to the client about the positive result? 1 Immediate birth is indicated. 2 This is the desired response at this stage of gestation. 3 Further testing is unnecessary with this desired outcome. 4 The result is inconclusive, indicating the need for further evaluation.

2 An NST indicates that the fetus is healthy because there is an active pattern of fetal heart rate acceleration with movement. The result is positive and desired; immediate birth is not required. Further testing is needed. If the pregnancy continues, another test of fetal well-being will probably be done. The results were positive, not inconclusive.

Before a client has a cardiac catheterization, an electrocardiogram (ECG) is performed, and hypokalemia is suspected. The nurse expects that the diagnosis will be confirmed by which diagnostic test? 1 Complete blood count 2 Serum potassium level 3 X-ray film of long bones 4 Blood cultures times three

2 Hypokalemia is suspected when the T wave on an ECG tracing is depressed or flattened; a serum potassium level less than 3.5 mEq/L (3.5 mmol/L) indicates hypokalemia. Complete blood count, x-ray film of long bones, and blood cultures times three will have no significance in the diagnosis of a potassium deficit.

The nurse is counseling a woman who has just been identified as having a multiple gestation. Why does the nurse consider this pregnancy high risk? 1 Postpartum hemorrhage is an expected complication. 2 Perinatal mortality is two to three times more likely in multiple than in single births. 3 Optimal psychological adjustment after a multiple birth requires 6 months to 1 year. 4 Maternal mortality is higher during the prenatal period in the setting of multiple gestation

2 Perinatal morbidity and mortality rates are higher with multiple-gestation pregnancies, because the greater metabolic demands and the possibility of malpositioning of one or more fetuses increases the risk for complications. Although postpartum hemorrhage does occur more frequently after multiple births, it is not an expected occurrence. Adjustment to a multiple gestation and birth is individual; the time needed for adjustment does not place the pregnancy at high risk. Maternal mortality during the prenatal period is not increased in the presence of a multiple gestation.

The nurse is providing postoperative care to a client with lung cancer who had a partial pneumonectomy. When inspecting the client's dressing, the nurse notes puffiness of the tissue around the surgical site. When the nurse palpates the site, the tissue feels spongy and crackles can be felt. How does the nurse describe this assessment finding? 1 Respiratory stridor 2 Subcutaneous emphysema 3 Bilateral 2+ pitting edema 4 Chest distention

2 There is air in the tissues and palpation results in a crackling sound referred to as subcutaneous emphysema. Respiratory stridor is a harsh, high-pitched sound usually produced on inspiration because of airway obstruction. Bilateral 2+ pitting edema is excessive accumulation of fluid in tissue spaces. The size of the chest is determined by the bony structure; a barrel chest with an increase in the anteroposterior (AP) diameter is associated with chronic obstructive pulmonary disease (COPD), not cancer of the lung.

Which client is at greatest risk for the development of a venous thrombosis? 1 A 76-year-old female with a 100-pack-per-year smoking history and hypertension 2 A 68-year-old male on bed rest following a left hip fracture 3 A 59-year-old male who is an intravenous drug user with hyperlipidemia 4 A 42-year-old female with Factor V Leiden mutation on warfarin

2 Venous thrombosis is the result of inflammation to a vein, hypercoagulability, venous stasis, or a combination of the three, known as Virchow triad. Bed rest and hip fracture are two major risk factors for the development of a thrombosis. While the other options present risk factors (cigarette smoking, drug abuse, and clotting disorders), the combination of the two (venous stasis and vessel injury) results in greatest risk for thrombus development.

When palpating a client's fundus on the second postpartum day, the nurse determines that it is above the umbilicus and displaced to the right. What does the nurse conclude? 1 There is a slow rate of involution. 2 There are retained placental fragments. 3 The bladder has become overdistended. 4 The uterine ligaments are overstretched.

3 A distended bladder will displace the fundus upward and laterally to the right. A slow rate of involution is manifested by slow contractions and uterine descent into the pelvis. If retained placental fragments were present, the uterus would be boggy in addition to being displaced, and vaginal bleeding would be heavy. From this assessment the nurse cannot make a judgment regarding overstretched uterine ligaments.

What should supportive nursing care at the beginning of the mother-infant relationship include? 1 Suggesting that the mother choose breastfeeding instead of formula feeding 2 Advising the mother to engage in rooming-in with the newborn at the bedside 3 Encouraging the mother to help out with simple aspects of her newborn's care 4 Observing the mother-infant interaction unobtrusively to evaluate the relationship

3 Holding, touching, and interacting with the newborn while providing basic care promotes attachment. The nurse's infant feeding preference should not be forced upon the mother. Although rooming-in helps promote attachment, not all women have the physical or emotional ability to provide 24-hour care to the newborn so early in the postpartum period. Early observation is not adequate; full evaluation of the relationship can be achieved only by allowing the mother ample time to interact with her baby.

A nurse in the postpartum unit must complete several interventions before a client's discharge from the hospital. The nurse plans to delegate some of the tasks to an unlicensed health care worker. Which activity must be performed by the nurse? 1 Taking the neonate's picture 2 Placing the infant car seat in the car 3 Comparing the identification bands of mother and infant 4 Preparing the discharge packet and distributing them to parents

3 It is the nurse's professional responsibility to compare the mother's and infant's identification bands one last time before discharge. This ensures that the correct infant is discharged with the mother. Taking the neonate's picture, placing the infant seat in the car, and preparing the discharge packets and distributing them to parents are all within the role of the nursing assistant and may be delegated safely.

The nurse is teaching a client to care for her episiotomy after discharge. Which priority instruction should the nurse include in her instructions? 1 Rest with legs elevated at least two times a day. 2 Avoid stair climbing for several days after discharge. 3 Perform perineal care after toileting until healing occurs. 4 Continue sitz baths three times a day if they provide comfort

3 Prevention of infection is the priority. Resting should be encouraged; however, it is not the priority at this time. Stair climbing may cause some discomfort but is not detrimental to healing. There is no limit to the number of sitz baths per day that the client may take if they provide comfort.

At a routine monthly visit, while assessing a client who is in her 26th week of gestation, the nurse identifies the presence of striae gravidarum. The nurse describes this condition to the client as what? 1 Brownish blotches on the face 2 Purplish discoloration of the cervix 3 Reddish streaks on the abdomen and breasts 4 A black line running between the umbilicus and mons veneris

3 Reddish streaks on the abdomen and breasts are striae gravidarum; they occur as a result of stretching of the breast and abdominal skin. These are known as "stretch marks." Chloasma refers to the condition where brownish blotches develop on the face. Purplish discoloration of the cervix is Chadwick sign. A black line running between the umbilicus and mons veneris is the linea nigra.

The nurse instructs a pregnant client regarding fetal growth and development. Which statement indicates that the client requires further teaching? 1 "The fetus keeps growing throughout pregnancy." 2 "The fetus may be underweight if it's exposed to smoke." 3 "The fetus gets nutrients from the amniotic fluid." 4 "The fetus gets oxygen from blood in the placenta."

3 The amniotic fluid provides protection, not nutrition; the fetus depends on the placenta, along with the umbilical blood vessels, for nutrients and oxygen. The statements that the fetus keeps growing throughout pregnancy, that it may be underweight if exposed to smoke, and that it gets oxygen from blood in the placenta all indicate that the client understands the teaching.

A nurse is caring for a client who is positive for hepatitis A. Which precautions should the nurse take? 1 Wear a gown when entering the client's room. 2 Use caution when bringing in the client's food. 3 Use gloves when removing the client's bedpan. 4 Wear a protective mask when entering the client's room.

3 Use gloves when removing the client's bedpan. The virus is present in the stool of clients with hepatitis A; therefore, standard precautions should be followed when handling excretions. The virus also may be present in urine and nasotracheal secretions. The Centers for Disease Control and Prevention (CDC) (Canada: Public Health Agency of Canada (PHAC)) indicate that only standard precautions are necessary when caring for a client who is positive for the presence of hepatitis A; if a client is incontinent or using an incontinence device, the CDC (Canada: PHAC) recommends that contact precautions be implemented. Bringing food to a client requires no precautions; however, disposable utensils should be used and utensils discarded following standard precautions because the client's nasotracheal secretions contain the virus. Hepatitis A usually is not transmitted via the air.

A client is admitted for hypertension, and serum electrolyte studies have yielded abnormal results. The scheduled workup includes a scan for an aldosteronoma. What gland is affected in aldosteronoma? 1 Kidney cortex 2 Thyroid gland 3 Pituitary gland 4 Adrenal cortex

4 An aldosteronoma is an aldosterone-secreting adenoma of the adrenal cortex. An aldosteronoma is not a tumor of the kidney cortex. An aldosteronoma is not a tumor of the thyroid gland. An aldosteronoma is not a tumor of the pituitary gland.

A 23-year-old woman comes to the clinic for a Pap smear. After the examination, the client confides that her mother died of endometrial cancer 1 year ago and says that she is afraid that she will die of the same cancer. Which risk factor stated by the client after an education session on risk factors indicates that further teaching is needed? 1 Obesity 2 High-fat diet 3 Hypertension 4 Late-onset menarche

4 Early-onset, not late-onset, menarche is a risk factor for endometrial cancer. A high-fat diet, hypertension, and obesity are all risk factors for endometrial cancer.

A pregnant client's blood test reveals an increased alpha-fetoprotein (AFP) level. Which condition does the nurse suspect that this result indicates? 1 Cystic fibrosis 2 Phenylketonuria 3 Down syndrome 4 Neural tube defect

4 Increased levels of alpha-fetoprotein in pregnant women have been found to reflect open neural tube defects such as spina bifida and anencephaly. Cystic fibrosis is a genetic defect that is not associated with the AFP level. A Guthrie test soon after ingestion of formula can determine whether an infant has phenylketonuria. Down syndrome is a chromosomal defect that is associated with a low AFP level.

A client is scheduled for a sonogram at 36 weeks' gestation. Shortly before the test she tells the nurse that she is experiencing severe abdominal pain. Assessment reveals heavy vaginal bleeding, a drop in blood pressure, and an increased pulse rate. Which complication does the nurse suspect? 1 Hydatidiform mole 2 Vena cava syndrome 3 Marginal placenta previa 4 Complete abruptio placentae

4 Severe pain accompanied by bleeding at term or close to it is symptomatic of complete premature detachment of the placenta (abruptio placentae). A hydatidiform mole is diagnosed before 36 weeks' gestation; it is not accompanied by severe pain. There is no bleeding with vena cava syndrome. Bleeding caused by placenta previa should not be painful.

A client undergoing presurgical testing before a total abdominal hysterectomy says to the nurse, "After I have this surgery I know my husband will never come near me again." What is the nurse's best initial response? 1 "You're underestimating his love for you." 2 "You're wondering about the effect on your sexual relations." 3 "You're worried that the surgery will change how others see you." 4 "You're concerned about how your husband will respond to your surgery."

4 Stating that the client is concerned about how her husband will respond to her surgery is an open-ended response that encourages further discussion without focusing on an area that the nurse, not the client, feels is the problem. Accusing the client of underestimating her husband's love denies the client's feeling and may cause feelings of guilt for questioning the partner's love. Wondering about the effect on sexual relations is too specific; the nurse does not have enough information to come to this conclusion. Worrying that the surgery will change how others see the client shifts the focus from the client's voiced concerns; the client specifically referred to her husband, not others.

Nonstress test (NST)

for antepartum evaluation of fetal well being performed during third trimester. noninvasive test that monitors the fhr to fetal movement. a doppler transducer(used to monitor the fhr) and a tocotransducer(used to monitor uterine contractions) are attached externally to a client's abdomen to obtain tracing strips. client pushes a button when she feels the fetus move.

Dumping syndrome

increase fat and protein, small frequent meals, lie down after meal to decrease peristalsis. Wait 1 hr after meals to drink

Thalassemia

inherited defect in ability to produce hemoglobin, leading to hypochromia

alpha-fetoprotein test

measures the level of AFP in pregnant women during the second trimester of pregnancy. Too much or too little AFP in a mother's blood may be sign of a birth defect or other condition.

placental abruption

premature separation of the placenta

hiatal hernia

protrusion of a part of the stomach upward through the opening in the diaphragm

Primordial prevention care

refers to prevention of the risk factors themselves at either the social or environmental level.

Primary Preventive Care

routine medical care and screening generally provided by physicians specializing in family practice, general internal medicine, and pediatrics

Tetralogy of Fallot (TOF)

set of four congenital heart defects occurring together

paracentesis

surgical puncture to remove fluid from the abdomen

Secondary Preventive Care

-Goal is to detect and treat illnesses in early stages with screenings -Blood Pressure/ HIV/Glaucoma/Cholesterol, Pap Smears, Mammograms

Prinzmetals variant angina

-Unpredictable -Caused by coronary artery vasospasm

What is the most important nursing action when measuring a client's pulmonary capillary wedge pressure (PCWP)? 1 Deflate the balloon as soon as the PCWP is measured. 2 Have the client bear down when measuring the PCWP. 3 Place the client in a supine position before measuring the PCWP. 4 Flush the catheter with a heparin solution after the PCWP is determined

1 Although the balloon must be inflated to measure the capillary wedge pressure, leaving the balloon inflated will interfere with blood flow to the lung. Bearing down will increase intrathoracic pressure and alter the reading. Although a supine position is preferred, it is not essential. Agency protocols relative to flushing of unused ports must be followed.

Two days after having a cesarean birth, a client tells the nurse that she has pain in her right leg. After an assessment the nurse suspects that the client has a thrombus. What is the nurse's primary response at this time? 1 Maintaining bed rest 2 Applying warm soaks 3 Performing leg exercises 4 Massaging the affected area

1 Although thrombophlebitis is suspected, before a definitive diagnosis can be made the client should be confined to bed so that further complications may be avoided. Applying warm soaks may cause vasodilation, which could allow a thrombus to dislodge and circulate freely. If a thrombus is present, massage may dislodge it and lead to a pulmonary embolism.

A client admitted to the high-risk unit with a threatened abortion anxiously asks the nurse, "Could this have happened because I had the flu?" How should the nurse respond? 1 "Tell me why you feel this way. Do you think that you did something to cause the bleeding?" 2 "We know that maternal infection sometimes results in spontaneous abortion. Perhaps the flu did cause it." 3 "I'm sure that there's nothing you could have done to cause this. You shouldn't worry about it." 4 "The primary healthcare provider will be here soon and will be better prepared to answer your questions. Why don't you wait until then?"

1 Asking the client to talk about how she feels encourages the client to discuss her fears and anxieties. Stating that the flu may have caused the spontaneous abortion gives inaccurate information; this conclusion has not been documented, and this response adds to the guilt felt by the client. Telling the client that there is nothing she could have done to cause the problem does not focus on the client's feelings; it cuts off communication between the nurse and the client. Telling the client to wait until the primary healthcare provider arrives denies the client's feelings, abdicates the nurse's responsibility to the client, and cuts off communication. Also, it may increase anxiety because it implies that the nurse is not adequately prepared to care for the client.

A client in labor begins to experience contractions 2 to 3 minutes apart and lasting about 45 seconds. Between contractions the nurse identifies a fetal heart rate (FHR) of 100 beats/min on the internal fetal monitor. What is the priority nursing action? 1 Notifying the healthcare provider 2 Resuming continuous fetal heart monitoring 3 Continuing to monitor the maternal vital signs 4 Documenting the fetal heart rate as an expected response to contractions

1 Bradycardia (baseline FHR slower than 110 beats/min) indicates that the fetus may be compromised, requiring medical intervention. Resuming continuous fetal heart monitoring may be dangerous. The fetus may be compromised, and time should not be spent on monitoring. Continuing to monitor the maternal vital signs is not the priority at this time. The expected FHR is 110 to 160 beats/min between contractions.

A client with ascites has a paracentesis, and 1500 mL of fluid is removed. For which immediate response is it most important for the nurse to monitor? 1 Rapid, thready pulse 2 Decreased peristalsis 3 Respiratory congestion 4 Increase in temperature

1 Fluid shifts from the intravascular compartment into the abdominal cavity, causing hypovolemia. A rapid, thready pulse [1] [2], which is indicative of shock, is a compensatory response to this shift. Decreased peristalsis is not likely to occur in the immediate period. After a paracentesis, intravascular fluid shifts into the abdominal cavity, not into the lungs. Increase in temperature is not the priority; body temperature usually is not affected immediately; an infection will take several days.

A client in the birthing suite has spontaneous rupture of the membranes, after which a prolapsed cord is identified. The nurse calls for help and with a sterile gloved hand moves the fetal head off the cord. What should the nurse anticipate? 1 Cesarean birth 2 Prolonged labor 3 Rapidly induced labor 4 Vacuum extraction vaginal birth

1 Immediate birth is necessary to prevent fetal hypoxia and death. Allowing a prolonged labor, inducing labor, or using vacuum extraction in a vaginal birth will increase pressure on the cord, resulting in fetal hypoxia.

To help prevent a cycle of recurring urinary tract infections in a female client, which instruction should the nurse share? 1 "Urinate as soon as possible after intercourse." 2 "Increase your daily intake of citrus juice." 3 "Douche regularly with alkaline agents." 4 "Take bubble baths regularly."

1 Intercourse may cause urethral inflammation, increasing the risk of infection; voiding clears the urinary meatus and urethra of microorganisms. Most fruit juices, with the exception of cranberry juice, cause alkaline urine, which promotes bacterial growth. Douching is no longer recommended because it alters the vaginal flora. Bubble baths can promote urinary tract infections.

A client at 10 weeks' gestation calls the clinic and tells a nurse that she has morning sickness and cannot control it. What should the nurse suggest to promote relief? 1 "Eat dry crackers before you get out of bed." 2 "Increase your fat intake before bedtime." 3 "Drink high-carbohydrate fluids with meals." 4 "Eat two small meals a day and a snack at noon."

1 Nausea and vomiting in the morning occur in almost 50% of all pregnancies. Eating dry crackers before getting out of bed in the morning is a simple remedy that may provide relief. Increasing fat intake does not relieve the nausea. Drinking high-carbohydrate fluids with meals is not helpful; separating fluids from solids at mealtime is more advisable. Eating two small meals a day and a snack at noon does not meet the nutritional needs of a pregnant woman, nor will it relieve nausea. Some women find that eating five or six small meals daily instead of three large ones is helpful.

Which hormone is crucial for ovulation and complete maturation of a client's ovarian follicles? 1 Luteinizing hormone 2 Follicle stimulating hormone 3 Gonadotropin releasing hormone 4 Human chorionic gonadotropin hormone

1 Ovulation and complete maturation of ovarian follicles can only take place in the presence of luteinizing hormone. However, follicle stimulating hormone initiates maturation of the follicles. Gonadotropin releasing hormone stimulates the pituitary gland to release follicle stimulating hormone and luteinizing hormone. Human chorionic gonadotropin hormone is released after implantation and is responsible for secretion of progesterone and estrogen during pregnancy.

A client presents to the emergency room with coughing and sudden wheezing. The nurse notes the client is progressing quickly into respiratory distress. The nurse identifies that the client is experiencing what problem? 1 An acute asthma attack 2 Acute bronchitis 3 Left-sided heart failure 4 Cor pulmonale

1 Symptoms for an acute asthma attack often are wheezing, coughing, dyspnea, and chest tightness. Cough, fever, and fatigue are often symptoms exhibited with acute bronchitis. Fatigue, breathlessness, weakness, shortness of breath, and fluid accumulation in the lungs are often signs of left-sided heart failure. Tiring easily, shortness of breath with exertion, lower leg edema, chest pain, and heart palpitations often are exhibited with cor pulmonale.

The nurse is caring for a client in her third trimester who is scheduled for an amniocentesis. What should the nurse do to prepare the client for this test? 1 Instruct her to void immediately before the test. 2 Tell her to assume the high Fowler position before the test. 3 Encourage her to drink three glasses of water before the test. 4 Advise her to take nothing by mouth for several hours before the test.

1 The client is instructed to void immediately before the test to help prevent injury to the bladder as the needle is introduced into the amniotic sac. The supine position with a hip roll under the right hip is the preferred position for this procedure. Telling the client to assume the high Fowler position before the test will cause the bladder to fill, making it vulnerable to injury as the needle is inserted into the amniotic sac. Encouraging the client to drink three glasses of water before the test is advised if the amniocentesis is being performed early during pregnancy. There is no reason to withhold food or fluid, because the test does not involve the gastrointestinal tract.

During the assessment of a client in labor, the cervix is determined to be dilated 4 cm. What stage of labor does the nurse record? 1 First 2 Second 3 Prodromal 4 Transitional

1 The first stage of labor is from zero cervical dilation to full cervical dilation (10 cm). The second stage is from full cervical dilation to delivery. The prodromal stage is before cervical dilation begins. The transitional phase is the first stage of labor, from 8 cm of dilation to 10 cm of dilation.

In a noisy room a sleeping newborn initially startles and exhibits rapid movements; however, the baby soon goes back to sleep. What is the most appropriate nursing action in response to this behavior? 1 Documenting an intact reflex 2 Assessing the infant's vital signs 3 Testing the infant's ability to hear 4 Stimulating the infant's respirations

1 The initial response is a reflection of the startle reflex; when the stimulus is repetitive, the response to the stimulus decreases. This decrease in response is called habituation and is expected. Assessing the infant's vital signs and stimulating the infant's respirations are not necessary because the neonate's response is expected. The infant is responding to noise and therefore hears.

A client is to undergo amniocentesis at 38 weeks' gestation to determine fetal lung maturity. What lecithin/sphingomyelin ratio (L/S ratio) is adequate for the nurse to conclude that the fetus's lungs are mature enough to sustain extrauterine life? 1 2:1 2 1:1 3 1:4 4 3:4

1 The lecithin concentration increases abruptly at 35 weeks, reaching a level that is twice the amount of sphingomyelin, which decreases concurrently. At 30 to 32 weeks' gestation, the amounts of lecithin and sphingomyelin are equal, indicating lung immaturity. A ratio of 1:4 does not reflect fetal lung maturity; nor does a ratio of 3:4.

Which phase of the woman's sexual response is characterized by elevation of the uterus? 1 Plateau phase 2 Orgasmic phase 3 Excitation phase 4 Resolution phase

1 The plateau phase occurs after the excitation phase, and excitation is maintained through the plateau phase, wherein the vagina expands and the uterus is elevated. Therefore elevation of the uterus is a characteristic of the plateau phase of a woman's sexual response. The orgasmic phase is characterized by uterine and vaginal contractions. In the excitation phase, the clitoris is congested and vaginal lubrication increases. The resolution phase is characterized by returning to the preexisting state.

nurse is assessing two clients. One client has ulcerative colitis, and the other client has Crohn disease. Which is more likely to be identified in the client with ulcerative colitis than in the client with Crohn disease? 1 Inclusion of transmural involvement of the small bowel wall 2 Higher occurrence of fistulas and abscesses from changes in the bowel wall 3 Pathology beginning proximally with intermittent plaques found along the colon 4 Involvement starting distally with rectal bleeding that spreads continuously up the colon

1 Ulcerative colitis involvement starts distally with rectal bleeding that spreads continuously up the colon to the cecum. In ulcerative colitis, pathology usually is in the descending colon; in Crohn disease, it is primarily in the terminal ileum, cecum, and ascending colon. Ulcerative colitis, as the name implies, affects the colon, not the small intestine. Intermittent areas of pathology occur in Crohn. In ulcerative colitis, the pathology is in the inner layer and does not extend throughout the entire bowel wall; therefore, abscesses and fistulas are rare. Abscesses and fistulas occur more frequently in Crohn disease.

What are the most common hormones produced in excess with hyperpituitarism? Select all that apply. 1 Prolactin 2 Growth hormone 3 Luteinizing hormone 4 Antidiuretic hormone 5 Melanocyte-stimulating hormone

1 2 The most common hormones produced in excess with hyperpituitarism are prolactin and growth hormone. Excessive stimulation of luteinizing hormone and antidiuretic hormone is also associated with hyperpituitarism, but less commonly than prolactin and growth hormone. Secretion of melanocyte-stimulating hormone stimulates adrenocorticotropic hormone, which indirectly stimulates the pituitary gland, thus leading to hyperpituitarism.

Which hormones are involved in building and maintaining healthy bone tissue? Select all that apply. 1 Insulin 2 Thyroxine 3 Glucocorticoids 4 Growth hormone 5 Parathyroid hormone

1, 4 Insulin works together with growth hormone to increase bone length, which helps to build and maintain healthy bone tissue. Thyroxine increases the rate of protein synthesis in all types of tissues. Glucocorticoids regulate protein metabolism to reduce or intensify the organic matrix of bone. Parathyroid hormone secretion stimulates bones to promote osteoclastic activity and release calcium into the blood when serum calcium levels are lowered.

A client is rooming in with her newborn. The nurse observes the infant lying quietly in the bassinet with the eyes open wide. What action should the nurse take in response to the infant's behavior? 1 Brightening the lights in the room 2 Encouraging the mother to talk to her baby 3 Wrapping and then turning the infant to the side 4 Beginning physical and behavioral assessments

2 A quiet, alert state is an optimal time for infant stimulation. Bright lights are disturbing to newborns and may impede mother-infant interaction. Wrapping and then turning the infant to the side is done for the sleeping infant. Physical and behavioral assessments are not the priorities; they may be delayed.

The nurse is educating new parents about circumcision. Which structure of the penis would this nurse tell the parents is removed during circumcision? 1 Glans 2 Prepuce 3 Epididymis 4 Vas deferens

2 Circumcision is a procedure that involves removal of the prepuce, a skin fold over the glans. The glans is the tip of the penis. The epididymis is the internal structure that promotes transportation of the sperm. The vas deferens carries the sperm from the epididymis to the ejaculatory duct.

A client in her 37th week of gestation calls the nurse at the clinic and reports, "My ankles are so swollen." Which intervention should the nurse recommend? 1 Limiting fluid intake during the day 2 Elevating her legs more frequently during the day 3 Restricting salt intake for the remainder of her pregnancy 4 Taking a mild diuretic that the healthcare provider will prescribe

2 Dependent edema in the ankles is a common occurrence during the latter part of pregnancy. It results from increased pressure of the uterus on the pelvic veins. Elevating the legs encourages venous return. Limiting fluid intake can be harmful; increased circulating blood volume during pregnancy must be maintained. Salt is necessary to retain fluid for the increased circulating blood volume during pregnancy. Diuretics are not utilized during pregnancy; they may decrease the circulating blood volume.

A nurse is obtaining a health history from a client with newly diagnosed cervical cancer. Which aspect of the client's life is most important for the nurse to explore at this time? 1 Sexual history 2 Support system 3 Obstetric history 4 Elimination patterns

2 During a health crisis the client will need support from significant others. The sexual history is important in diagnosis and the obstetric history and elimination patterns are important parts of the medical history; however, none are the priority at this time.

An infant of a diabetic mother is admitted to the neonatal intensive care unit. What is the priority nursing intervention for this infant? 1 Clamping the cord a second time 2 Obtaining heel blood to test the glucose level 3 Starting an intravenous (IV) infusion of glucose in water 4 Instilling an ophthalmic antibiotic to prevent an eye infection

2 Hypoglycemia may be present because of the sudden withdrawal of maternal glucose and increased fetal insulin production, which continues after birth. The umbilical vein may be needed to start an IV; it should not be damaged. An IV infusion of glucose should not be started until the blood glucose level has been determined. Instilling an antibiotic into the eyes can be delayed until the blood glucose level has been determined.

A client who menstruates regularly every 30 days asks a nurse on what day she is most likely to ovulate. Because the client's last menses started on January 1, the nurse should tell her that ovulation should occur on which day in January? 1 7 2 16 3 24 4 29

2 Ovulation should occur on January 16. The time between ovulation and the next menstruation is relatively constant. In a 30-day cycle the first 15 days are preovulatory, ovulation occurs on day 16, and the next 14 days are postovulatory. January 7, January 24, and January 29 all reflect inaccurate calculation of the date of ovulation.

A primary healthcare provider prescribes an antihypertensive medication. Which over-the-counter medication should the nurse teach the client to avoid because it has the potential to counteract the effect of the antihypertensive? 1 Omeprazole 2 Acetaminophen 3 Docusate sodium 4 Pseudoephedrine

2 Pseudoephedrine has a pressor effect that may counteract antihypertensive medications, causing an increase in blood pressure. Omeprazole does not interact with antihypertensives. However, it can increase the action of phenytoin, digoxin, clopidogrel, and cyclosporine. Acetaminophen does not have to be avoided when receiving an antihypertensive. Docusate sodium does not have to be avoided when receiving an antihypertensive.

A nurse on the high-risk unit is caring for a client with severe preeclampsia. Which intervention is the most effective in preventing a seizure? 1 Providing a plastic airway 2 Controlling external stimuli 3 Having emergency equipment available 4 Keeping calcium gluconate at the bedside

2 Reducing lights, noise, and stimulation minimizes central nervous system irritability, which can trigger a seizure. A plastic airway will not prevent a seizure. Available emergency equipment will not prevent a seizure, although oxygen and suction equipment may be useful after a seizure. Calcium gluconate is the antidote for magnesium sulfate toxicity; it does not prevent seizures.

The nurse admits a client with preeclampsia to the high-risk prenatal unit. What is the next nursing action after the vital signs have been obtained? 1 Calling the primary healthcare provider 2 Checking the client's reflexes 3 Determining the client's blood type 4 Administering the prescribed intravenous (IV) normal saline

2 The client is exhibiting signs of preeclampsia. The presence of hyperreflexia indicates central nervous system irritability, a sign of a worsening condition. Checking the client's reflexes will help direct the primary healthcare provider to appropriate interventions and alert the nurse to the possibility of seizures. Although the primary healthcare provider will be called, a complete assessment should be performed first to obtain the information needed. Determining the client's blood type is not necessary at this time; assessment of neurologic status is the priority. An IV may be started after the assessment; however, a more dilute saline solution will be prescribed.

What is the best advice a nurse can provide to a pregnant woman in her first trimester? 1 "Cut down on drugs, alcohol, and cigarettes." 2 "Avoid drugs and don't smoke or drink alcohol." 3 "Avoid smoking, limit alcohol consumption, and don't take aspirin." 4 "Take only prescription drugs, especially in the second and third trimesters."

2 The first trimester is the period when all major embryonic organs are forming; drugs, alcohol, and tobacco may cause major defects. Cutting down on these substances is insufficient; they are teratogens and should be eliminated. Even 1 oz of an alcoholic drink is considered harmful; baby aspirin may be prescribed to some women who are considered at risk for pregnancy-induced hypertension; however, not during the first trimester. Medications, unless absolutely necessary, should be avoided throughout pregnancy; however, the first trimester is most significant.

Which hormone increases the rate of protein synthesis in a client? 1 Estrogen 2 Thyroxine 3 Parathormone 4 Vitamin D

2 Thyroxine increases the rate of protein synthesis in all the body tissues. Estrogen stimulates bone-building, which is known as osteoblastic activity. Parathormone promotes osteoclastic activity in a state of hypocalcemia. Vitamin D and its metabolites are produced in the body and transported in the blood to promote the absorption of calcium and phosphorus from the small intestine.

A nurse is obtaining a health history from a client with the diagnosis of peptic ulcer disease. Which client statement provides evidence to support the identification of a possible contributory factor? 1 "My blood type is A positive." 2 "I smoke one pack of cigarettes a day." 3 "I have been overweight most of my life." 4 "My blood pressure has been high lately."

2 "I smoke one pack of cigarettes a day." Smoking cigarettes increases the acidity of gastrointestinal secretions, which damages the mucosal lining. While blood type O is more frequently associated with duodenal ulcer, type A has no significance. Being overweight is unrelated to peptic ulcer disease. High blood pressure is not directly related to peptic ulcer disease.

A nurse receives a call from the emergency department about a client with tuberculosis (TB) who will be admitted to the medical unit. Which precaution should the nurse take? 1 Put on a gown when entering the room 2 Place the client with another client who has TB 3 Wear a particulate respirator when caring for the client 4 Don a surgical mask with a face shield when entering the room

3 A high-particulate filtration mask that meets Centers for Disease Control (CDC) performance criteria (Canada: Public Health Agency of Canada [2013] Canadian Tuberculosis Standards, 7th edition) for a tuberculosis respirator must be worn to protect healthcare providers from exposure to the Mycobacterium tuberculosis organism. Airborne transmission-based precautions do not require a gown unless contact with respiratory secretions is anticipated. The client should be placed in a private room with negative pressure and multiple full air exchanges per hour vented to the outside environment. A surgical mask with a face shield is inadequate to prevent transmission of the tuberculosis microorganism.

A client asks the nurse at the prenatal clinic whether she may continue to have sexual relations while pregnant. What is one indication that the client should refrain from intercourse during pregnancy? 1 Fetal tachycardia 2 Presence of leukorrhea 3 Premature rupture of membranes 4 Imminence of the estimated date of birth

3 Ruptured membranes leave the products of conception exposed to bacterial invasion. Intact membranes act as a barrier against organisms that may cause an intrauterine infection. Fetal tachycardia may occur during sex, but there is no evidence that it is harmful for the fetus. Leukorrhea is common because of increased production of mucus containing exfoliated vaginal epithelial cells; intercourse is not contraindicated by leukorrhea. Intercourse is not contraindicated near the estimated date of birth if the membranes are intact; modification of sexual positions may be needed because of the enlarged abdomen.

While the nurse is caring for a client in active labor whose fetus is at station 0, the client's membranes rupture spontaneously. The nurse determines that the fluid is clear and odorless. What should the nurse do next? 1 Change the bedding. 2 Notify the practitioner. 3 Assess the fetal heart rate (FHR). 4 Obtain the client's blood pressure.

3 The FHR will reflect how the fetus tolerated the rupture of the membranes; if there is compression of the cord, it will be reflected in a change in the FHR. Although the client's comfort is important, it is not the priority. Although the practitioner should be notified, it is not the priority. Blood pressure is not influenced by rupture of the membranes.

A nurse instructs a client with viral hepatitis about the type of diet that should be ingested. Which lunch selected by the client indicates understanding about dietary principles associated with this diagnosis? 1 Turkey salad, french fries, sherbet 2 Cottage cheese, mixed fruit salad, milkshake 3 Salad, sliced chicken sandwich, gelatin dessert 4 Cheeseburger, tortilla chips, chocolate pudding

3 The diet should be high in carbohydrates, with moderate protein and fat content. A salad, chicken and gelatin meal is the best choice. Turkey salad, french fries, and sherbet are too high in fat. Cottage cheese, mixed fruit salad, and a milkshake are dairy products and may cause lactose intolerance; the hepatitis virus injures the intestinal mucosa and reduces the client's ability to metabolize lactose. Cheeseburger, tortilla chips, and chocolate pudding are too high in fat.

Which cartilage is also known as the Adam's apple? 1 Costal 2 Cricoid 3 Thyroid 4 Arytenoid

3 The thyroid cartilage is commonly known as the "Adam's apple" and is the largest of the cartilages that comprise the laryngeal skeleton. The costal cartilage is only found at the anterior ends of the rib. The cricoid cartilage lies below the thyroid cartilage. The arytenoid cartilage works with the thyroid cartilage in facilitating vocal cord movement.

While mopping the kitchen floor, a client at 37 weeks' gestation experiences a sudden sharp pain in her abdomen with a period of fetal hyperactivity. When the client arrives at the prenatal clinic, the nurse examines her and detects fundal tenderness and a small amount of dark-red bleeding. What does the nurse conclude is the probable cause of these clinical manifestations? 1 True labor 2 Placenta previa 3 Partial abruptio placentae 4 Abdominal muscular injury

3 Typical manifestations of abruptio placentae are sudden sharp localized pain and small amounts of dark-red bleeding caused by some degree of placental separation. True labor begins with regular contractions, not sharp localized pain. There is no pain with placenta previa, just the presence of bright-red bleeding. There are no data to indicate that the client sustained an injury.

An adolescent woman who has become sexually active asks the nurse, "What's the most effective way to prevent a pregnancy?" Which method of preventing pregnancy should the nurse tell her is most effective? 1 Birth control pills 2 Spermicidal foam 3 Condoms 4 An intrauterine device

4 According to the U.S. Centers for Disease Control and Prevention, having an intrauterine device inserted provides a 99% effective means of preventing pregnancy. The oral contraception pill has a high 91% effective rate when used correctly. Condoms are 82% effective and the barrier can reduce (but not eliminate) the risk of sexually transmitted infections. Spermicidal foam is a 72% effective means of preventing pregnancy; however, its effectiveness also depends on correct, consistent use. Although refraining from sexual intercourse is the most effective form of birth control (100% effective), this client has come to the nurse for advice about how to prevent pregnancy while being sexually active.

What statement by a breast-feeding mother indicates that the nurse's teaching regarding stimulating the let-down reflex has been successful? 1 "I will take a cool shower before each feeding." 2 "I will drink a couple of quarts of fat-free milk a day." 3 "I will wear a snug-fitting breast binder day and night." 4 "I will apply warm packs and massage my breasts before each feeding."

4 Applying warm packs and massaging the breasts before each feeding help dilate milk ducts, promote emptying of the breasts, and stimulate further lactation. Taking a cool shower before each feeding will contract the milk ducts and interfere with the let-down reflex. Heavy consumption of milk products is not required to stimulate the production of milk. Breast binders may inhibit lactation by fooling the body into thinking that milk secretion is no longer needed.

The nurse is creating a dietary plan for a client with cholecystitis who has been placed on a modified diet. Which will be most appropriate to include in the client's dietary plan? 1 Offer soft-textured foods to reduce the digestive burden 2 Offer low-cholesterol foods to avoid further formation of gallstones 3 Increase protein intake to promote tissue healing and improve energy reserves 4 Decrease fat intake to avoid stimulation of the cholecystokinin mechanism for bile release

4 Fat intake stimulates cholecystokinin release that signals the gallbladder to contract, causing pain. Soft-textured foods are unnecessary. Eating low-cholesterol foods to avoid further formation of gallstones is not true for all clients with cholecystitis; low-cholesterol foods are necessary if the cholecystitis is precipitated by cholelithiasis and the stones are composed of cholesterol. An increase in protein intake is necessary to promote tissue healing and improve energy reserves after a cholecystectomy, but is not as important as fat intake for cholecystitis.

One hour after a birth a nurse palpates a client's fundus to determine whether involution is taking place. The fundus is firm, in the midline, and two fingerbreadths below the umbilicus. What should the nurse do next? 1 Encourage the client to void. 2 Notify the practitioner immediately. 3 Massage the uterus and attempt to express clots. 4 Continue periodic assessments and record the findings

4 Immediately after birth the uterus is 2 cm below the umbilicus; during the first several postpartum hours the uterus will rise slowly to just above the level of the umbilicus. These findings are expected, and they should be recorded. Encouraging the client to void is unnecessary; if the bladder is full, the uterus will be higher and pushed to one side. Notifying the healthcare provider is unnecessary; involution is occurring as expected. Massage is used when the uterus is soft and "boggy."

A pregnant client is scheduled for ultrasonography at the end of her first trimester. What should the nurse instruct her to do in preparation for the sonogram? 1 Empty her bladder. 2 Avoid eating for 8 hours. 3 Take a laxative the night before the test. 4 Increase fluid intake for 1 hour before the procedure.

4 In the first trimester when fluid fills the bladder, the uterus is pushed up toward the abdominal cavity for optimum ultrasound viewing. The bladder must be full, not empty, for better visualization of the uterus. The gastrointestinal tract is not involved in ultrasound preparation.

What is the primary responsibility of a nurse teaching the pregnant adolescent? 1 Instructing her about the care of an infant 2 Informing her of the benefits of breast-feeding 3 Advising her to watch for danger signs of preeclampsia 4 Encouraging her to continue regularly scheduled prenatal care

4 It is not uncommon for adolescents to avoid prenatal care; many do not recognize the deleterious effect that lack of prenatal care can have on them and their infants. Instruction in the care of an infant can be done in the later part of pregnancy and reinforced during the postpartum period. Informing the client of the benefits of breast-feeding should come later in pregnancy but not before the client's feelings about breast-feeding have been ascertained. Advising the client to watch for danger signs of preeclampsia is necessary, but it is not the priority intervention at this time.

The nurse is caring for an assignment of postpartum clients. Which factor puts a client at increased risk for postpartum hemorrhage? 1 Breastfeeding in the birthing room 2 Receiving a pudendal block for the birth 3 Having a third stage of labor that lasts 10 minutes 4 Giving birth to a baby weighing 9 lb 8 oz (4309 g)

4 The chance of postpartum hemorrhage is five times greater with large infants because uterine contractions may be impaired after the birth. Early breastfeeding will stimulate uterine contractions and lessen the chance of hemorrhage. Having a pudendal block for the birth does not contribute to postpartum hemorrhage, because the anesthetic for a pudendal block does not affect uterine contractions. Ten minutes is a short third stage; a prolonged third stage of labor, 30 minutes or more, may lead to postpartum hemorrhage.

A male infant is born at 28 weeks' gestation weighing 2 lb 12 oz (1247 g). What does the nurse expect to note when performing an assessment? 1 Staring eyes 2 Absence of lanugo 3 Descended testicles 4 Transparent red skin

4 Transparent red skin is expected due to the absence of subcutaneous fat tissue. Preterm infants born nearer to term have open, staring eyes. Preterm infants are generally born with large amounts of lanugo, which begins to thin just before term and by 40 weeks is found only on the shoulders, back, and upper arms. The preterm infant's scrotum is small, and the testicles are usually high in the inguinal canal.

Alpha-fetoprotein (AFP)

A blood test that measures the level of alpha-fetoprotein in the mothers' blood during pregnancy as an indicator of possible birth defects in a fetus

Turner Syndrome

A chromosomal disorder in females in which either an X chromosome is missing, making the person XO instead of XX, or part of one X chromosome is deleted.

The nurse is caring for a client with a hiatal hernia. The client states that favorite beverages include ginger ale, apple juice, orange juice, and cola beverages. Of the four the client listed, which is the only beverage that should remain in the client's diet? 1 Ginger ale 2 Apple juice 3 Orange juice 4 Cola beverages

Correct 2 Apple juice Apple juice is not irritating to the gastric mucosa. Carbonated beverages like ginger ale distend the stomach and promote regurgitation. The acidity of orange juice aggravates the disorder. Most colas should be avoided because they contain caffeine, which causes increased acidity and aggravates the disorder; also they are carbonated, which distends the stomach and promotes regurgitation.

Nägele rule for EBD

Determine first day of last menstrual period (LMP), subtract 3 months, add 7 days plus 1 year • Alternatively add 7 days to LMP and count forward 9 months

Frequency of contractions

beginning of one contraction to the beginning of the next

tubal ligation

blocking the fallopian tubes to prevent fertilization from occurring

positive rebound tenderness

is a clinical sign that is elicited during physical examination of a patient's abdomen by a doctor or other health care provider. It is indicative of peritonitis. It refers to pain upon removal of pressure rather than application of pressure to the abdomen.

Dependent edema usually occurs

with severe protein deficiency and heart failure. Spoon-shaped nails usually occur with iron deficiency anemia